Alberto L. García‐Basteiro

Universitat de Barcelona

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Elisa López‐Varela

Barcelona Institute for Global Health

Simon I Hay

Institute for Health Metrics and Evaluation

Edson Mambuque

Manhiça Health Research Centre

Rakhi Dandona

Public Health Foundation of India

Christopher J L Murray

Institute for Health Metrics and Evaluation

G Anil Kumar

Public Health Foundation of India

Ali H. Mokdad

University of Washington

Naohiro Yonemoto

University of Toyama

Ai Koyanagi

Parc Sanitari Sant Joan de Déu

Florian Fischer

Charité - Universitätsmedizin Berlin

Cooperative Institutions

Institute for Health Metrics and Evaluation

2,444

University of Washington

2,234

Tehran University of Medical Sciences

481

University College London

389

Seattle University

366

Universitat de Barcelona

355

Auckland University of Technology

338

University of Sydney

336

Barcelona Institute for Global Health

296

Veterans Health Administration

242

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Vaccinate fast but leave no one behind: a call to action for COVID-19 vaccination in Spain

Communications Medicine (2021)

Jeffrey V. Lazarus Quique Bassat Javier Crespo Gonzalo Fanjul Alberto L. García‐Basteiro

During the first five months of 2021, Spain's COVID-19 vaccination campaign progressed slowly and failed to reach marginalised populations. Here, we discuss how, despite recent improvements, it remains important to further engage key stakeholders to ensure nobody is left behind. Lazarus et al. outline the barriers slowing down the COVID-19 vaccination campaign in Spain. They issue a call to action for all stakeholders to improve access to vaccines, with a particular emphasis on reaching marginalised populations.

nobody

Call to action

2019-20 coronavirus outbreak

10.1038/s43856-021-00014-2

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Citations (10)

Towards host-directed therapies for tuberculosis

Nature Reviews Drug Discovery (2015)

Alimuddin Zumla Jeremiah Chakaya Michael Höelscher Francine Ntoumi Roxana Rustomjee

10.1038/nrd4696

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Citations (112)

High Yield of Home-Based TB Diagnosis Among Newly Diagnosed Patients With HIV

JAIDS Journal of Acquired Immune Deficiency Syndromes (2019)

Elisa López‐Varela Durval Respeito Silvia Blanco Manuel Gimo Charfudin Sacoor

To the Editors: Tuberculosis (TB) remains an important public health concern and a leading cause of disease and death. People living with HIV (PLHIV) are at a higher risk of developing TB, and TB is the largest cause of death among this population, accounting for 37% of AIDS-related deaths in 2016.1 Early TB diagnosis among PLHIV is crucial for improved patient outcomes, and yet long diagnostic delays in high TB and HIV settings continue to be reported.2 Different active case finding studies have shown the utility and feasibility of home-based (HB) TB testing among TB contacts.3,4 Despite some criticisms about the relative low yield and high costs of these strategies, they have the advantage of expanding heath care access beyond the health system while reducing transmission in the health facilities. Nonetheless, beyond routine screening at the health facility level, there are no specific national guidelines recommending active TB case finding among patients with HIV newly diagnosed at the community or household level. The aim of this study was to determine the community prevalence of pulmonary TB among a cohort of PLHIV newly diagnosed through HB HIV testing and counseling (HTC) in Mozambique. The study was performed in 2015 in the area covered by the health and demographic surveillance system located in the Manhiça District. This is a semirural area in southern Mozambique, with a particularly high HIV and TB burden. The HIV prevalence in the district among adults aged 18–47 years was 39.7% in 2012,5 and the incidence rate of laboratory-confirmed TB was 847/100,000 among PLHIV.6,7 UNAIDS estimates that in 2017, 59% [95% confidence interval (CI): 49 to 70] of PLHIV in Mozambique knew their status.8 Before study initiation, HIV testing was mainly provided through voluntary counseling and testing. TB diagnosis was mostly based in sputum smear testing, and Xpert MTB/RIF was only performed among retreatment cases or those with a positive culture 2 or 5 months after treatment initiation. This study was nested within a larger cohort of adults older than 18 years newly diagnosed with HIV with independent approval by the national bioethics committee of Mozambique (Ref: 75/CNBS/2014).9 The larger cohort consisted of randomly selected adult individuals living in the Manhiça District Hospital's catchment area diagnosed with HIV through HB-HTC. HB-HTC was performed using a list of adults randomly selected among the residents recorded in the health and demographic surveillance system. Three attempts were made to contact each individual before defining the status as absent, and replacement was used when household residents could not be found. Only PLHIV with previously negative or reported unknown HIV status were eligible to participate. Enrollment into the TB study was done in the same visit in which the patient was HIV diagnosed by community-based workers trained in HTC and in basic TB-screening procedures. Individuals consenting to participate were screened for TB following the World Health Organization symptom–based screening algorithm (reported fever, cough, night sweats, and weight loss).10 All patients, regardless of the presence of any TB-compatible symptoms, were asked to provide a spontaneous spot sample of sputum, which was collected outdoors following specific infection control training. Samples were transported to the study laboratory for Xpert MTB/RIF, and smear and liquid culture testing. Patients with TB-compatible symptoms were referred to the closest health facility for clinical management. Patients with any positive test were further contacted for TB treatment initiation. All newly diagnosed PLHIV were referred to the Manhiça District Hospital HIV chronic care clinic for enrollment in care and routine follow-up. Those who successfully linked to care were passively followed up for a year, to assess TB incidence. Passive follow-up clinical data were obtained from the MDH HIV clinical records. The number needed to screen (NNS) and the number needed to test for a laboratory-confirmed TB case were calculated by dividing the number of participants consenting to participate and those providing a sample, respectively, among the number of confirmed TB cases. Among 318 PLHIV diagnosed through HB-HTC, 97.2% (309) consented to participate. Fifty-seven (18.4%) were later identified as previous HIV cases who did not disclose their HIV status, and thus, 252 PLHIV (81.6%) were finally included in the analysis. Among them, the mean age was 35.9 years (SD: 14.0) and 56.2% were women. A total of 104 (41.3%) described any of the following symptoms: cough of any duration: 58 (55.8%); fever: 35 (33.7%); weight loss: 51 (49.0%); and night sweats: 53 (51.0%). Twenty-one patients (8.3%) reported having a household member with TB in the previous year and 4 (1.6%) reported having a previous history of TB treatment. Ninety-one participants (36.1%) were able to provide a spontaneous sputum sample, of whom 32 were asymptomatic (Fig. 1). Four participants had laboratory-confirmed TB, one of whom was asymptomatic and one had history of previous TB treatment. Eight participants had a nontuberculous mycobacteria isolated (M. intracellulare n = 3; M. spp n = 3, M. peregrinum n = 1, and M. scrofulaceum n = 1) The prevalence of laboratory-confirmed TB among newly diagnosed PLHIV was 1.6% (4/252) (95% CI: 0.4 to 4.0). The prevalence of laboratory-confirmed TB was 4.4% (4/91) (95% CI: 1.2 to 10.9) and 2.9% (3/104) (95% CI: 0.6 to 8.2) among those providing samples and among patients who had a positive screen for TB, respectively (Fig. 1). The NNS for a laboratory-confirmed TB case was 63 and the number needed to test was 23.FIGURE 1.: Study flowchart and overall results from community TB screening and testing among newly diagnosed HIV individuals.Linkage to HIV care, defined as having a CD4 count test in the following 12 months after diagnosis, was 37.3% (94/252) for all participants. The median initial CD4 cell count was 328 cells/mL (interquartile range 195–505). Three of the 4 confirmed TB cases linked to care with a median CD4 of 208 (interquartile range 52–1061). Among the remaining newly diagnosed HIV participants linked to care, 2 additional TB cases were diagnosed in the following year, yielding a TB incidence of 2.2% (95% CI: 0.3 to 7.7). This is one of the few studies reporting on single encounter–coupled HIV and TB testing at the patient household in sub-Saharan Africa.3,11–13 Importantly, we found a high participation rate for TB screening and testing in a population of newly diagnosed HIV participants. Although the sample size is limited, the prevalence of microbiologically confirmed TB among newly diagnosed patients is high, taking into account that this population (with unknown or previously negative HIV status) is unlikely to be severely immunosuppressed. The prevalence and incidence are in line with previous burden of disease assessments conducted in the district based on health facility–based TB diagnoses.6 The NNS falls within the range of other studies in sub-Saharan Africa.11 Nonetheless, the NNS is, as expected, higher than the weighted mean (NNS: 10) obtained in a systematic review that included facility-based patients with HIV.14 This study had some limitations. First, it was a nested in a larger cohort, thus the sample size was not a priori calculated and was small. Second, we only collected one spot sputum sample at the time of the visit, far from the recommendations of most optimal sample collection procedures (at least 2 samples, one of them at the early morning). Finally, patient's follow-up was passive, and thus, it is likely that the true prevalence at the time of HIV diagnosis, as well as the incidence rate during the first-year postscreening, is underestimated. In conclusion, we found a high TB prevalence among newly diagnosed patients with HIV in the community. Joint TB and HIV testing strategies performed at the household level are feasible in rural settings and contribute to early diagnosis of both conditions. The recommendations of TB screening among PLHIV are supported by World Health Organization recommendations, although further on guidance on household-level implementation needs to be provided. Cost-effectiveness of this intervention and further studies with larger sample size that include patient follow-up to assess in individual-level benefits in treatment outcomes need to be conducted.

10.1097/qai.0000000000001947

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Citations (3)

Tuberculosis on the rise in southern Mozambique (1997–2012)

European Respiratory Journal (2017)

Alberto L. García‐Basteiro Rafaela Ribeiro Joe Brew Charfudin Sacoor Salomé Valencia

Tuberculosis (TB) remains an important public health concern and a leading cause of disease and death worldwide. Mozambique is one of the few high-burden countries where incidence rates have not improved in recent years. The estimated TB incidence rate in 2014 was 552 cases per 100 000 population and the estimated case detection rate is very low at just around 39% [1, 2]. The National Tuberculosis Control Programme (NTP) in Mozambique was launched in 1977 and expanded nationwide in 1985 [3]. The TB patient registration system began in 1984 and short-course therapy followed in the late eighties [3, 4], despite a civil war which resulted in a shortage of qualified medical staff and supplies, and fragile deployment systems. By the year 2000, the Directly Observed Therapy, Short-Course (DOTS) strategy had complete coverage in all districts of Mozambique [4]. In Manhiça District, Mozambique, tuberculosis incidence rates underwent a 3-fold increase over 16 years (1997–2012) The authors would like to thank the District Health Authorities (Fausta Temba) and NTP for their constant support. We would also like to thank Henriquez Mbeve and Alberto Bila, as well as all of the CISM and MDH clinicians and staff who have contributed to TB diagnosis in the district over the study period.

Economic shortage

Tuberculosis control

Disease Control

10.1183/13993003.01683-2016

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Citations (20)

Monitoring of First-line Drug Resistance Mutations Outside the Scope of Xpert MTB/RIF Ultra is Needed for Successful Control of DR-TB in Southern Mozambique

Clinical Infectious Diseases (2023)

Carla Mariner-Llicer Belén Saavedra Edson Mambuque Neide Gomes Shilzia Munguambe

Abstract Multidrug-resistant(MDR) tuberculosis in Southern Africa is of great concern, exacerbated by the spread of a clone harboring a mutation missed by Xpert Ultra. In Southern Mozambique, the presence of such mutation and rising cases of non-MDR isoniazid resistance highlights the need to ensure accurate detection of antimicrobial-resistance in the country.

clone (Java method)

Scope (computer science)

Tuberculosis control

10.1093/cid/ciad684

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Citations (2)

Prevalence and clinical characteristics of pulmonary TB among pregnant and post-partum women

The International Journal of Tuberculosis and Lung Disease (2022)

Dinis Nguenha Sozinho Acácio Adrià Murias‐Closas N. Ramanlal Belén Saavedra

SETTING: Antenatal care (ANC) and postpartum care (PPC) clinic in Manhiça District, Mozambique.OBJECTIVE: To estimate the prevalence of TB among pregnant and post-partum women and describe the clinical characteristics of the disease in a rural area of Southern Mozambique.METHODS: We conducted a cross-sectional TB prevalence study among pregnant and post-partum women recruited from September 2016 to March 2018 at the Manhiça Health Care Center (MHC). We recruited two independent cohorts of women consecutively presenting for routine pregnancy or post-partum follow-up visits.RESULTS: A total of 1,980 women from the ANC clinic and 1,010 from the PPC clinic were enrolled. We found a TB prevalence of 505/100,000 (95% CI: 242-926) among pregnant women and 297/100,000 (95% CI: 61-865) among post-partum women. Among HIV-positive pregnant women, TB prevalence was 1,626/100,000 (95% CI: 782-2,970) and among postpartum HIV-positive women, TB prevalence was 984/100,000 (95% CI: 203-2,848).CONCLUSIONS: The burden of TB was not higher in postpartum women than in pregnant women. Most TB cases were detected in HIV-positive women. TB screening and diagnostic testing among pregnant and postpartum women attending ANC and PPC clinics in Manhiça District is acceptable and feasible.

Post partum

Cross-sectional study

10.5588/ijtld.21.0567

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Citations (2)

Assessing the immunological response to hepatitis B vaccination in HIV-infected patients in clinical practice

Vaccine (2012)

Guillermo Mena Anna Llupià Alberto L. García‐Basteiro Consolación Díez Agathe León

Vaccination schedule

Immunosuppression

Hepatitis B

Hepatitis B vaccine

10.1016/j.vaccine.2012.03.018

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Citations (24)

How do we measure adherence to anti-tuberculosis treatment?

Expert Review of Anti-infective Therapy (2016)

Salomé Valencia Montserrat León‐García Irene Losada Guillermo Sequera Manuel Fernández Quevedo

Introduction: Completion of anti-tuberculosis (TB) treatment is of paramount importance for TB patients, as well as for the global efforts of TB control. However, there is neither a gold-standard measure to monitor adherence to TB treatment nor a widely used definition for different levels of adherence.Areas covered: in this review we aim to describe the different methods used to measure patients' adherence to anti-TB treatment, identifying their main strengths and limitations, with a focus on low resource settings.Expert commentary: there is a need for continuing the quest for a low cost, reliable and acceptable measure of adherence to TB treatment. We should harmonize treatment adherence measurement to allow adequate comparison of different interventions aimed at increasing adherence to TB treatment, although the way we ensure adherence can affect adherence endpoints themselves. The accuracy of adherence measurement is of importance in the context of drug clinical development.

Medication Adherence

Gold standard (test)

10.1080/14787210.2017.1264270

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Citations (40)

Remote analysis of sputum smears for mycobacterium tuberculosis quantification using digital crowdsourcing

PLoS ONE (2022)

Lara García Delgado María Postigo Daniel Cuadrado Sara Gil-Casanova Álvaro Martínez

Worldwide, TB is one of the top 10 causes of death and the leading cause from a single infectious agent. Although the development and roll out of Xpert MTB/RIF has recently become a major breakthrough in the field of TB diagnosis, smear microscopy remains the most widely used method for TB diagnosis, especially in low- and middle-income countries. This research tests the feasibility of a crowdsourced approach to tuberculosis image analysis. In particular, we investigated whether anonymous volunteers with no prior experience would be able to count acid-fast bacilli in digitized images of sputum smears by playing an online game. Following this approach 1790 people identified the acid-fast bacilli present in 60 digitized images, the best overall performance was obtained with a specific number of combined analysis from different players and the performance was evaluated with the F1 score, sensitivity and positive predictive value, reaching values of 0.933, 0.968 and 0.91, respectively.

Crowdsourcing

Case finding

10.1371/journal.pone.0268494

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Citations (2)

What is the true tuberculosis mortality burden? Differences in estimates by the World Health Organization and the Global Burden of Disease study

International Journal of Epidemiology (2018)

Alberto L. García‐Basteiro Joe Brew Brian Williams Martien W. Borgdorff Frank Cobelens

The World Health Organization (WHO) and the Global Burden of Disease (GBD) study at the Institute for Health Metrics and Evaluation (IHME) periodically provide global estimates of tuberculosis (TB) mortality. We compared the 2015 WHO and GBD TB mortality estimates and explored which factors might drive the differences.We extracted the number of estimated TB-attributable deaths, disaggregated by age, HIV status, sex and country from publicly available WHO and GBD datasets for the year 2015. We 'standardized' differences between sources by adjusting each country's difference in absolute number of deaths by the average number of deaths estimated by both sources.For 195 countries with estimates from both institutions, WHO estimated 1 768 482 deaths attributable to TB, whereas GBD estimated 1 322 916 deaths, a difference of 445 566 deaths or 29% of the average of the two estimates. The countries with the largest absolute differences in deaths were Nigeria (216 621), Bangladesh (49 863) and Tanzania (38 272). The standardized difference was not associated with HIV prevalence, prevalence of multidrug resistance or global region, but did show correlation with the case detection rate as estimated by WHO [r = -0.37, 95% confidence interval (CI): -049; -0.24] or, inversely, with case detection rate based on GBD data (r = 0.44, 95% CI: 0.31; 0.54). Countries with a recent national prevalence survey had higher standardized differences (higher estimates by WHO) than those without (P = 0.006). After exclusion of countries with recent prevalence surveys, the overall correlation between both estimates was r = 0.991.A few countries account for the large global discrepancy in TB mortality estimates. The differences are due to the methodological approaches used by WHO and GBD. The use and interpretation of prevalence survey data and case detection rates seem to play a role in the observed differences.

Global Health

10.1093/ije/dyy144

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Citations (37)